This document summarizes the medical history and examination of a 68-year-old male who presented to the emergency department after a fall two days prior. He has a history of controlled hypertension. On examination, he has swelling and excruciating pain in his right hip area. Relevant test results are included. Surgical fixation is proposed, and the risks and benefits of different surgical procedures are discussed. Perioperative considerations and anesthetic techniques are also outlined.

1. DR.CHAVI SEHGAL
ASSITANT PROFESSOR MLBMC JHANSI
DR.ASHOK SINGH (JR)

2. *68 Year male with H/O fall 2 days back , H/O
controlled hypertension for last 10 yrs taking
Atenolol 25mg BD, Ecospirin 75 mg , Rosuvastatin
20 mg OD presents to ED
*Trauma was sustained by slipping in the bathroom
which resulted in swelling of Rt. Hip area with
excruciating pain , he was rushed to the casualty
by his son within 1 hr of fall.

3. *Patient conscious , B.P-170/100 mmHg,P.R-94/min,
swelling in right lower extremity, Resp & CVS-WNL
*Inv-Hb-10gm/dl , TLC-10,400cell/mm3
*Platelet count -1.8 Lakh/μL , RBS-130mg/dl
*Urea-60 mg/dl , creatinine-1.8mg/dl,
*Na+ -134 Meq/L ,K+-4.2 Meq/L,
*S.Albumin-3.9 mg/dl,
*ECG-LVH(T-inversion v1-v4)
*2D ECHO-diastolic dysfunction , EF-58%

4. *Immobilization at # site & prompt surgical fixation
*Two types of surgeries proposed-
head conserving / replacement
*Joint replacement - effective procedure for relief of
disability d/t loss of function
*Growing demand , now performed as ambulatory Sx –
’FAST TRACK SYSTEM’

5.  Patients posted for orthopedics with
broad spectrum
of problems
 Elderly /co-morbidities Young/associated trauma
 AGE IS NOT A DETERRENT FACTOR FOR SURGERY
 Multidisciplinary approach is the key to handle !
 Limited end organ reserve in elderly.

6. D/t high circulating PTH & low vitamin D , GH
Disproportionate loss of Trabecular bone – high risk for
stress #- ( Minimal impact trauma)
Bones at risk are-

7. Loss of articular cartilage, inflammation.
C/F- pain, reduced mobility, deformed joints.
Hands – swelling of -DIP (Heberden's nodes)
- PIP (Bouchard's nodes).
No systemic manifestations
Important for surgical positioning of painful joints.

8. Joint synovitis - bone erosion, loss of joint integrity.
Systemic disease - exacerbations & remissions.
C/F- pain/stiffness in multiple joints lasting >1 hr after
initiating activity.
Boggy , tender joint
Patients on NSAIDs - assess for GI , renal C/C
Glucocorticoids - need‘stress-dose’ for
their operations.
DMARD’S started early but  risk of infection

9. Fusion of the axial skeleton- loss of spinal mobility.
Challenging airway -
TMJ synovitis – limited MPG
Damaged cricoarytenoid joints –narrow glottis-
interferes passage of ETT
C-spine Arthritis - Flexion of head -Odontoid
process d/p into cervical spine- - Quadriparesis
Pre-op cervical flexion-extension radiographs
required to plan for awake fiber-optic (AFOI)
Ossification of ligaments blocks access to CNB

10.  Vascular – Atherosclerosis -  SVR
 Fibrotic myocytes -  contractility.
  β-adr responsiveness -conduction delays,
arrhythmias / ectopic
LV SYSTOLIC/DIASTOLIC dysfunction coEXIST (HFpEF)
 left ventricular compliance
 LVDP
 Non compliant heart & blood vessels can neither
tolerate hypovolemia nor exaggerated transfusion
! Consider fluid administration carefully!

11.  Loss of elastic recoil. Barrel
 Loss of height of the vertebrae/rib cage shaped chest.
 Lung compliance   early collapse of small airways
air trapping.
 Chest wall compliance  –  work of breathing.
 Ventilatory responses to hypoxia, hypercapnia impaired.
Lung volume changes–
 Diffusing capacity , VC ,FEV1- 
 TLC /FRC unchanged.
 RV - by 5% -10% / decade
 CC-  with age & encroaches on FRCV/Q mismatch

12. STRUCTURAL- Nephrosclerosis
FUNCTIONAL-  GFR
Na+ handling, concentrating & diluting capacity  –
predisposes to dehydration and fluid overload.
STRUCTURAL-  in liver size , hepatic blood flow
10%/decade
FUNCTIONAL-Phase I / Phase II metabolism slows down

13. Aging causes memory decline to affect ADL
Neuronal shrinkage & Neurotransmitters involved
COGNITIVE ISSUES
DEMENTIA-5-8% , >65 yrs
Cause-ALZIEMERS with Agitation ,Depression ,Sleep changes
DELERIUM- 10% , >65 yrs
Fluctuating changes in level of consciousness accompanied by
other mental symptoms
DEPRESSION-8-16%, >65 yrs

14.  Diagnosis/Screening-NOT easy , use AD8 Questionnaire
 Informed consent- surrogate/Advanced directives
 Technique related -Patient co-operation is an issue for R.A
 Pain management

15. FRAILITY
Refers to a loss of physiologic reserve that makes a person
more vulnerable to disability during & after stress-(6.9%)
CRITERIA
 Weight Loss
 Exhaustion
 Physical Activity
 Walk Time
 Grip Strength
fatigue Wt. loss
weakness
COMPONENTS

16. CBC- Hb / TLC / DLC / ESR / Platelet
 RBS
Cardiopulmonary
- CX-R,PFTs, ABG, SPO2 , resting ECG
- 2DEcho / Dobutamine stress tests
Renal - Serum creatinine , Blood urea,
- S.Electrolytes
Musculoskeletal Airway /Spine
-Range of limb and neck movements Assessment
for positioning on table and for regional blockade
should be made

17. Done on factors:-
(1) Age/comorbidity
(2) Elective/ urgent
(3) Blood loss /fluid shifts
Risk more related with the presence of co-morbidities than with
the age of the patient!
Abnormal noninvasive cardiac testing pre-op rarely changes mx
in orthopedic sx
 Morbidity not  by coronary interventions.
 Restenosis is added risk if anticoagulants discontinued before sx &
peri-op bleeding  if they are not stopped.

18. WHAT SHOULD BE DONE?
*The answer is hemodynamic stress reduction
*Use of β blockers should be continued /started in
high risk patient {target H.R of < 80 bpm}
*Should be performed within 48 hours of admission
* Optimization of co-morbidities should be done as
early as possible, as delays  morbidity

19. Preoperative traction
O2 therapy - for first 48 hours , Hypoxemia!!
Large bore I/V access (non-dependent
arm for laterally positioned pt.)
Cross-matched blood must be available
DVT prophylaxis is required ( If CNB is planned )
Antibiotic prophylaxis
Prevention of pressure sores
Invasive monitoring seldom indicated

20. Anterior / Lateral approach
*surgeons prefer lateral posterior approach , pt. in lateral
decubitus position
*Compromises oxygenation-owing to V/Q mismatch
*Prevent pressure on the axillary artery /brachial plexus by
the dependent shoulder, place a roll /pad beneath the
upper thorax

21. No anesthetic plan is superior
REGIONAL ANESTHESIA
*Epidural space area 
*Permeability of duramater  Dosage requirements of
* CSF volume anesthetics 
* A given volume of epidural - more cephalic spread
- shorter duration of block

22. ADVANTAGE DISADVANTAGE
1-MENTAL STATUS ASSESMENT 1-PATIENT REFUSAL
2- VASCULAR FLOW 2-SEDATION REQUIREMENT/O2
3- DVT(  FIBRINOLYSIS) 3-HAEMODYNAMIC INSTABILITY
4- BLOOD LOSS(MAP-45-55 mmHg) 4-DELAYED ONSET
5- POCD (OPIOID SPARING),
NO AIRWAY INSTRUMENTATION
5-EARLY WEARING OFF
6- POST OP ANALGESIA 6-MULTIPLE BODY REGION SX CANNOT BE
DONE
7-EARLY MOBILIZATION

23. *SUB ARACHNOID BLOCK(SAB)
*EPIDURAL ANESTHESIA(EA)
*CSE
*PERIPHERAL NERVE BLOCKS(PNB)
-For hip arthroplasty, 3-in-1 block
(femoral/obturator /lateral cutaneous of thigh)
-A lumbar plexus block(LPB) also blocks the sciatic
nerve, which has a component supplying the hip

24. *Profound block upto T-10 achieved by small amount
of L.A
*Main challenge is - control the intrathecal spread
*Hyperbaric LA“sink” while hypobaric LA“swim” in a
way that level of spread depends on interaction of
density of LA with pt. posture
Midline approach/Sitting position-At L2-L3
interspace
*3.5ml of 0.5% hyperbaric bupivacaine injected

25. Lateral position
*When pt operated in lateral position S.A
given with pt lying on their side in L2-L3
space (hip schedule for sx is upwards )
*hypobaric solution is created by adding
3.5ml isobaric bupivacaine + 1.5ml
distilled water

26. *For EA ,sudden LOR as the needle passes
through ligamentum flavum & enters the
epidural space
*Introduce catheter with marked end in front
through the Tuohy needle until the desired
depth
*Catheter marking in cm-5.5-16.5(10.5cm- 2
ring,15.5cm-3 ring ,20.5cm-4 rings)
*Remove Tuohy needle holding catheter
tightly

27. FEMORAL NERVE
BLOCK
Nerve supply to hip joint -obturator,
inferior /superior gluteal nerves
Technique:1-Nerve stimulation
 Mark the inguinal ligament , Palpate
FA about 2 to 3 cms below
 Insert a 22 G , 3 inch needle
perpendicular to skin lateral to FA and
elicit paresthesias , Inject 10ml of L.A

28. *2-USG- USG transducer placed over
inguinal crease , FA & FV visualized
in C/S
*Just lateral to artery & deep to
fascia iliaca FN appears as spindle
shaped ’HONEY COMB’ texture
* Needle inserted lateral & cephalad
to an angle of 450
* After careful aspiration 30-40 ml
of L.A is injected

29. *3-fascia iliaca technique- once
inguinal ligament & FA identified ,
IL is divided into thirds,
*2 cm distal to the junction of the
M2/3rd & L1/3rd, needle inserted in
cephalad direction & 2 “pops” felt
* After careful aspiration 30-40 ml of
L.A is given.

30. *Patient positioned supine & a
point 2 cm medial & 2 cm distal
to ASIS is identified.
*A short 22 G needle inserted &
directed laterally, observing for a
“pop” as it passes through fascia
lata.
*A field block is performed with
10-15 ml of L.A

31. * In Lat decubitus position palpate midline.
* Draw a line through lumbar spinous processes & both intercristal
line identified & connected with a line at level of L4.
* PSIS is then palpated & line is drawn cephalad parallel to 1st line
* A 10-15 cm needle is inserted at the point of intersection between
the transverse line & intersection of the lat & middle 3rd of the 2nd
sagittal lines.
*Needle advanced (<3 cm past the depth at which transverse process
contacted ) in an ant direction until a femoral motor response
elicited (quadriceps contraction) & inject L.A

32. BALANCED GA WITH ETI-
Bleeding reduced by modest hypotension
Delayed Emergence from G.A
Maintenance of Normothermia
ADVANTAGE DISADVANTAGE
1-EARLY ONSET 1-AIRWAY INSTRUMENTATION
2-AS LONG AS NEEDED 2-HAEMODYNAMIC ALTERNATION
3-MULTIPLE SX AT 1 TIME 3-IMPAIRMENT OF NEURLOGIC
EXAMINATION
4-PPV
5-GREATER PT ACCEPTANCE
CONTROVERSY
APOPTOSIS,APP GENE

33. PHARMACOLOGIC FACTOR CHANGE WITH AGING IMPORTANCE
ABSORPTION  GASTRIC PH
 GASTRIC EMPTYING  ABSORPTION
 ABSORPTION SURFACE
 SPLANCHIC BLOOD FLOW
DISTRIBUTION  BODY FAT  VOD,LIPOPHILIC DRUGS
α1 GLYCOPROTEIN  FREE FRACTION OF
BASIC DRUGS
 ALBUMIN  FREE FRACTION OF
ACIDIC DRUGS
 BODY WATER  CONC OF POLAR DRUGS
METABOLISM  HEPATIC METABOLISM  BIOTRANSFORMATION
ELIMINATION  GFR  ELIMINATION ,pH &
ELECTROLYTE DISTURBSNCE
 RENAL TUBULAR
FUNCTION

35. *Short acting & less lipid soluble drugs

Propofol
Fentanyl
Rocuronium
Atracurium
Sevoflurane
Isoflurane

36. *SPO2, EtCO2, ECG, NIBP, Temp
*Invasive arterial B.P monitoring-in pt with
limited LVF/with massive blood loss
*CVP
*Cardiac Output monitoring-is used to guide
fluid therapy
*Cerebral O2 Saturation
*Neuro muscular monitoring
*Urine output

37. Patient position:
*In lateral position, risk of excessive lateral flexion/ pressure on
the dependent limbs
Hypothermia:
*Orthopedic O.T. colder, with a higher velocity airflow
*Hypothermia causes poor wound healing , infection ,
coagulopathy
Fluid warmers/blankets should be used routinely
Blood loss:
* Ranges from 300-1500 ml may double in the first 24 hours
postop
*During TKR with an intra-operative tourniquet, most blood loss
occurs at recovery

38. *Polymethylmethacrylate(PMMA)
BCIS
*Hypoxia, hypotension, unexpected LOC , cardiac arrest
occurs at time of cementation, prosthesis insertion, joint
reduction, tourniquet deflation in a patient undergoing
cemented bone sx
DEBRIS
*Fat, marrow , cement particules , air , bone particules, &
aggregates of platelets & fibrin

39. 1.Monomer absorbtion
2.Embolisation - Cement undergoes exothermic
reaction (72-120 0C) expands – intramedullary prdebris
forced into circulation
3.Histamine release - type 1 hypersensitivity
4.Complement factors – Anaphylatoxins
RISK FACTORS-
-Old age ,comorbidities,
-Bony metastases,
-Pathological #,
-Intertrochanteric #

40. *In high risk cases discuss risks-benefit of uncemented
/cemented arthroplasty
* Avoid N2O &  O2 concentration at the time of cementation
* PAC/TEE/Good haemostasis
* Medullary lavage
* Venting the bone permits air to escape from the end of the
cement plug
* If BCIS suspected, O2 concentration should be  to 100% &
continued in postoperative period
* Resuscitation with I/V fluids/Vasopressors/Inotropes

41. FAT EMBOLISM
*What are Fat Emboli?
*Fat embolization and FES are not synonymous
*FE-C/C of skeletal trauma/sx involving instrumentation of
medullary canal
versus
*FES-physiological response to FE-multi system dysfunction (<1%)
*Onset within 24-72 hours, A/W long bone /pelvic #, > closed #
Mortality: 10-20%

42. General factor- Males , 10-39 years
Post traumatic hypovolemic state
Reduced cardiopulmonary reserve
Injury related factors- Multiple # , B/L femur #,
lower extremity #
Sx related factors- Intramedullary reaming/
nailing after femoral # , B/L procedure
Joint replacement with high volume
prosthesis

43. Triad of-
Dermatological Signs(rash)
Pulmonary Dysfunction Neurological (nonspecific)
(hypoxemia)-75%

44. GURD’S CRITERIA
Major Features (at least 1)
*Respiratory insufficiency
*Cerebral involvement
*Petechial rash
Minor Features (at least 4)
*Pyrexia ,Tachycardia ,Jaundice
*Retinal , Renal changes
Laboratory Features
*Fat Microglobulinemia
*Anemia , Thrombocytopenia ,High ESR

45. Sign Score
Petechial rash 5
Diffuse alveolar infiltrates 4
Hypoxemia -PaO2< 70 mm Hg 3
Confusion 1
Fever >38°C (>100.4°F) 1
H.R >120 beats/min 1
R.R > 30 / min 1
Score > 5/16 required for diagnosis of FES

46. Prophylaxis
Immobilization - Early fixation
Supportive Medical Care
*Maintenance of adequate oxygenation , ventilation
*Maintenance of hemodynamic stability
*Administration of albumin/blood products
*Use of steroids controversial!
*Prophylaxis of DVT
*Heparin/LMW dextran/Ethanol

47. What is DVT? Clot in deep veins of the legs!
C/F- pain , swelling , tenderness, discoloration of surface
veins

48. Adapted from: Greer IA. Bailliere’s Clin Obstet Gynaecol 1997;11:403-30.
Factors intrinsic to the
patient
Factors related to
underlying disease or
medical condition
Factors introduced by
medical or surgical
treatment
• Age
• Obesity
• Immobility
• History of thrombosis
• Thrombophilia
• Varicose veins
• Venous insufficiency
• Pregnancy
• Trauma
• Heart failure/MI
• Malignancy
• Concomitant
medication
• Chemotherapy
• Orthopaedic surgery
• Major surgery
• Caesarean section

49. Occurs when blood clot breaks loose / travels to the lungs
C/F -shortness of breath, sharp rib/chest pain , occasionally
hemoptysis, light-headedness, or collapse
Pt. with symptomatic PE have 18-fold higher risk of death
than with DVT alone

50. HISTORY/EXAMINATION
CHEST X-RAY/ECG/D-dimers
DUPLEX ULTRASOUND/VENOGRAPHY
Spiral CT chest/V:Q scan /Pulmonary Angiogram
COMPLICATIONS OF DVT
Short-term- Prolonged Hospitalization, Bleeding C/C, Local
extension,
Long-term-Post-Thrombotic Syndrome, PHTN ,Recurrent DVT
Most hospitalized patients
with DVT will have NO
SYMPTOMS or SIGNS!

51. Risk of VTE in Hospitalized Pt.
Geerts WT, et al. Chest 2008;358:381S-453S.
Patient Group DVT Prevalence (%)
Medical Patients 10-20
General Surgery 15-40
Major Gynecologic Surgery 15-40
Major Urologic Surgery 15-40
Neurosurgery 15-40
Stroke 20-50
Hip and Knee Arthroplasty,
Hip Fracture Surgery
40-60
Major Trauma 40-80
Spinal Cord Injury 60-80
Critical Care Patients 10-80

52. MUST be given to all elderly pt under going orthopedic
procedures confined to bed > a day
Mechanical-
-Compression stockings
-Intermittent pneumatic compression devices
-IVC filters

53. 1. Antiplatelet (aspirin 50-100 mg/d)
2. Coumarins (Warfarin)-Adjusted-dose started
preop or evening after sx (INR target-2.5 )
3. UFH-5000 U S/C 8 hrly (monitor ApTT)
4. LMWH (Enoxaparin)- started 12 hr before sx or 4-
6 hr after sx-40 mg S/C OD
5. Fondaparinux (Factor Xa Inh)-2.5 mg OD S/C
6. XIMELAGATRAN (DTI)-36 mg BD( oral)

54. 1-Anticoagulant -prophylaxis & treatment of DVT
LMWH
- recommended over UFH (IV/SC) for initial therapy
- do not require monitoring of coagulation
- efficient when started preoperatively but risk of bleeding 
- continued for at least 10 days in LOW risk & extended to 28
to 35 days in high risk
2-Thrombolytics - severe, possibly fatal PE

55. Antiplatelet’s
• Low dose aspirin / NSAID’S -No restriction
• Clopidogrel/Ticlopidine- stop 7-10/14 days
respectively prior & continue 2 hrs after EC removal
• Tirofiban/Eptifibatide-stop 8 hr prior
• Abciximab-stop 24-48 hr prior
LMWH
• An interval of 12 hrs after administration of usual
dose of LMWH and placement of CNB
• With larger doses of LMWH - delay should be
extended to 24 hours
• EC removal at least 8-12 hrs after last LMWH dose,
or 1 to 2 hrs before the next

56. UFH S/C - No C/I If total daily dose <10,000 U
UFH I/V- Delay CNB 2-4 hrs after last dose monitor ApTT
restart 1 hr after procedure
Warfarin-
Discontinue 4-5 days before CNB-Evaluate INR(2-3)
Thrombolytics/Fibrinolytics
No available data ( follow fibrinogen level)

57. Decision to initiate rehabilitation, depends on whether there
is or not any perioperative C/C
Cardiac Complications
*ACC/AHA guidelines recommend pre-op cardiac testing in
pts at  risk on basis of clinical risk / type of sx
*Older pts have  risk of myocardial morbidity/mortality
after orthopedic sx
Respiratory Complications
*Age related, exacerbated in arthritis
*Embolization of bone marrow debris to the lungs
Neurologic Complications-POCD

58. POST OPERATIVE COGNITIVE DYSFUNCTION
Short term deterioation of intellectual function ( memory /
conc)-25-50%
 Detected days to weeks after sx.
 Duration of several weeks to permanent.
 Not affected -GA or RA
 Diagnosed by Neuropsychological testing
Risk factors
 Age/comorbidities, Alcohol
 Psychotropic medication, Preoperative cognitive impairment
 Perioperative hypoxemia, hypotension, abnormal
electrolytes,infection, BZDs , Anticholinergic

59. *Prophylactic continuation of medications.
*Identifying at risk patient
*Maintaining proper sleep cycle
*IV Fluids & Electrolytes correction
* exposure to- Antihistaminic, opioids, BZD,
*Maintain Hct >30%,
*Maintain O2 saturation > 90%
*Pain control-Nerve Blocks, Gabapentin, opioids by rotation
*Early rehabilitation

60. Oxygen: for the first 72 hours postoperatively.
Analgesia
-Epidural / PCA / BLOCKS
-Intra articular inj. Of L.A with opioids
-Paracetamol- 1 g/6 hours, given orally/ rectally.
-NSAIDs used with caution, in elderly
-Midazolam infusions or baclofen- to ease quadriceps
muscle spasm
Fluid balance:
Stringent monitoring is mandatory because blood loss
may double in the first 24 hours.

61. TECHNIQUE
*Innervation of the knee -TN, CPN, ON, & FN.
*RA- SAB / CSE / femoral & sciatic block.
*Advantages of SBTKR - exposure to risks of one
anesthetic, one postoperative course of pain,
reduced rehabilitation & an earlier return to
baseline function.
*SBTKA however, has a higher incidence of
perioperative complications, including MI ,FES,
& thromboembolic events.

62. *Age ≥ 75 yr
*ASA class III
*Active ischemic heart disease (positive stress test)
*Poor ventricular function (LVEF < 40%)
*Oxygen-dependent pulmonary disease
*IDDM
* Renal insufficiency
* Pulmonary hypertension
* Steroid-dependent asthma
* Morbid obesity (BMI > 40)
* Chronic liver disease
* Cerebrovascular disease

63.  Compressing device applied over extremities to control
circulation for a period of time to  intra operative
bleeding.
Better operating condition ”BLOOD LESS FIELD”
Depends on following variables:-
 Patient’s age
 Skin condition
 Blood pressure
 Shape/size of extremity

64. Cuff applied over limited padding.
Cuff dimensions
 large enough to comfortably encircle the limb for uniform
pressure.
 width of the inflated cuff should be > half the limb diameter.
 Before inflation, limb should be elevated for approx. 1 min &
tightly wrapped with an elastic bandage distally to
proximally.

65.  Determined by gradually  tourniquet pressure until arterial
blood flow distal to cuff is interrupted
 50-100 mmHg above Systolic B.P
 Upper limb-250 mmHg
 Lower limb-350 mmHg
 Occlusion time kept minimum-Safe limit of 1-3 hours.
 Asses operative situation at 2 hrs ,if anticipated duration >2hr
then deflate for 10 min & subsequently 1 hr interval.

66. Prerequisites for application-
Adequate hydration, Blood Volume , Normothermia
 SCD
 PVD
 CRUSH INJURY
 DM NEUROPATHY
 H/O DVT
 PE

67. Muscle change-due to compression /
ischemia of the tissue over time.
Endothelial integrity disrupts  tissue edema
colder limbs D/t heat loss.
Problems -
Glycogen , ATP , NAD 
CELLULAR
HYPOXIA  ACIDOSIS

68. Inflation- Exsanguination of limb- venous/ arterial pressure.
  in SVR, in HR,MAP, after 30-60 min of inflation.
  in PAP can occur in poor ventricular compliance.
 prolonged inflation-systemic hypertension develops
reflecting cellular ischemia cannot be reduced by
deepening anesthesia -use vasodilators
Deflation- Reperfusion of ischemic limb-
 Sudden  venous /arterial pressure
 Sudden  in SVR Pooling of blood in extremities

69. A washout of acidic by products occurs from ischemic limb to
systemic circulation after Deflation
Transient metabolic acidosis leads to ( in EtCO2).
Changes reversed with in 30 min of deflation
 in Lactic Acid, K+, PaCO2,
 in PO2, in pH

70. COMBINATION OF NERVE COMPRESSION & ISCHEMIA
 Direct pressure of nerves beneath tourniquet ( shearing
stress) leads to evidence of nerve injury
 Upper limb- Radial>Ulnar>Median Nerve
 Lower limb-Common Peroneal Nerve-
Implication in use of CNB – when tourniquet Inflation(> 2 hrs)
causes post operative neuropraxia

71.  Poorly defined dull aching ,burning sensation at the site
of application about 1 hour after inflation.
 Correlates with degree of cellular acidosis.
 Not relieved by narcotics , nerve blocks , EMLA.
 Deflate the tourniquet for 10-15 min & reinflate it.

72. Inflation-  in core body temperature
Deflation- in core body temperature (0.7 0C)
Inflation- Hypercoagulable state
Deflation— Fibrinolytics activity –anticoagulation
( POST TOURNIQUET BLEEDING)

73. Monitoring and I/V access
*Standard monitoring is required
*Large-bore I/V access on the non-operative side
*NIBP monitoring either on the non-operative
side, or on the lower leg.
Anesthetic technique
*1-G.A using an armoured tracheal tube and PPV
*2-Interscalene approach(ISB) to brachial plexus -
improves operative conditions,  blood loss,
good muscle relaxation

74. Patient position
*Sitting / beach chair position
*No excess strain on lumbar spine
*Torso securely strapped/head ring
*Access to airway difficult, ETT
must be taped
Intraoperative problems
*At start of operation, while
positioning, drop in B.P ,
bradycardia accompany change
from supine to sitting-
vasopressors required
*At risk of air embolism from open
veins at the operative site

75. MAIN INTRAOPERATIVE PROBLEM-
*Anticipated blood loss - depends on type of previous
prosthesis and the number of components to be revised.
*Pre-donation of autologous blood when sx A/w with blood
loss > 750-1500 ml
Acute Normovolaemic Haemodilution
*Technique in which whole blood is removed through
Phlebotomy while circulating volume maintained with
acellular fluid
*Eliminates need for Allogenic B.T.
* The blood requires no testing
*  risk of transfusion reaction/infections
*Blood(2-4 U) kept at room temp for 4 hr at 6 0C

76. SPINE SURGERY
INDICATIONS
*Neurologic dysfunction
*Structural deformity / Pathologic lesions
Essential to discuss preoperatively stability of the CERVICAL SPINE
with the surgeon
Neurological assessment:- SHOULD BE DOCUMENTED
* 1.Avoid further deterioration during intubation , positioning /
hypotensive anesthesia.
* 2.Muscular dystrophies involve bulbar muscles,  risk of aspiration.
* 3.Level of injury & time elapsed since insult are predictors of
physiological derangements which occur peri-operatively.

77. *Induction & intubation in supine position
*Turn prone as a single unit
*Neck in neutral position
*Head turned to the side / face on a cushioned holder
*Arms at the sides with the elbow flexed
*Chest should rest on parallel rolls to facilitate ventilation

78. Anesthetic problems of prone position
Monitor disconnects
Airway:
ETT kinking /dislodgement/Edema of upper airway
Head and Neck:
Hyper flexion / hyper extension of neck
Excess cervical rotation - kinking of vertebral artery
Eyes: pressure over eyes:- retinal injury /corneal abrasion
Blood Vessels: Kinking of FV with marked flexion of the hip
Abdominal -epidural venous pressure bleeding 
Nerves: Brachial plexus / Ulnar N/ CP/ LCNOT compression

79. *Lightening anesthesia during procedure & observing patient’s
ability to move to command. Evaluates functional motor
integrity.
Anesthesia requirements:
* Easy, rapid to institute , quickly antagonized
* Awakening should be smooth
* No pain/recall during the test
Anesthetic techniques:
Volatile/Midazolam/ Propofol / Remifentanyl -based anesthesia
Disadvantages:
* Risks of falling from the table / extubation
* Provides information at the time of the wake-up only
* Does not assess sensory pathways

80. *Better understanding of geriatric pathophysiology
*Safer anesthetic technique
*Multimodal / site specific analgesia
*Better monitors
*Physiotherapy & early ambulation